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Funding creativity

The organisations or institutions most able to fund and promote creative solutions have the resources but it is unusual for them to embrace novel ideas. Perhaps because they are accountable to stakeholders, risk averse and have rigid governance structures enforced by people with no stake in the outcome, rewarded instead for enforcing process. Decisions taken by such organisations are vulnerable to influence. Here are ten ways competitors stem funding for novel ideas:

1. Nominate: Get nominated as a grant reviewer on a funding committee on the basis of ‘expertise’ in their field.
2. Spook: Express concern that the applicants don’t seem to be aware of other funded projects on the same topic. Committees are easily spooked by the idea that applicants might be generating ideas that compete with something that has already been funded. The details don’t matter as long as whatever the committee ‘expert’ cites sounds like it might be relevant.
3. Foster doubt: Express concern that in their ‘expert’ opinion the project won’t succeed especially if the applicant could be accused of being unfamiliar with the context in which they intend to operate. Committees will be relying on their member’s special ‘expertise’ and are unlikely to disagree.
4. Cast aspersions: Note that the applicants don’t have the relevant expertise. It needs some imagination but always possible. No one is accomplished in every facet.
5. Magnify: Make much of reports that the pilot studies were inconclusive and by corollary risky. Novel ideas usually are. If the pilot studies showed promising results they make the remark that further research of this untested, risky idea is therefore probably unnecessary.
6. Argue: Present arguments why the budget requested is too high- in the current economic climate there is always room for economy. If the grant is approved having the budget slashed should slow competitors down.
7. Impugn: Comment that the chief investigator doesn’t have a strong enough track record to deliver on this project. Innovators doing something new are unlikely to have done anything exactly like this before. It spooks committees who might worry about any possibility that the money will be wasted. Sexism and racism, when it is subtle makes this easier.
8. Choose: Find another project on the list, led by someone who isn’t a threat, that is ‘so much better’ and of course less risky and would make a ‘big’ difference in practice. Committees would be happy to hear that the subject expert thinks they’d be funding something that would be so much more likely to meet a need.
9. Gossip: Express concern that even though they don’t ‘know’ the applicants personally, they’ve heard rumours that the applicants don’t produce good work. The doubts should generate enough anxiety to make some reviewers rethink their enthusiasm for a project.
10. Ambush: If such attempts at heading off the applicants at the pass fails and the committee funds the project- there’s always a chance for a competitor to stop them publishing their results later on. There’s lots of scope to recommend rejection of any paper- inadequate literature reviews, debated methodology, concerns about sample size, participant attrition, conflicting ideas about analysis of the data, failure to acknowledge the limitations of the methods. If all else fails someone can always find typographical and formatting errors that cast doubt on the whole manuscript- after all there is ‘lots of competition for space’ and the best journals receive ‘so many more papers than they can publish’.

On the other side of the fence if you are a determined innovator there is an opportunity buried here. On whom does your future depend if not on yourself? How do you innovate in a world that is viewed by some as being so small that if you have even a little then they don’t have enough? How are you being so resourceful that this doesn’t matter? A lean medicine approach is not about big projects nor reliant on big grants. Lean medicine is fuelled by the imagination and resourcefulness of champions.

Why innovators should learn to embrace feedback

Lean innovators often work in isolation and not surprisingly the innovator is emotionally invested in her idea. She has conceived the idea, developed it, spent time and resources on bringing the idea to life. This makes criticism of her brain-child very hard to bear.

The temptation is to be defensive. To shout down the critic. To take the view that the person offering an opinion hasn’t understood the brilliance of what has been brought to the world. The cure for this sort of pain is to begin with the end in mind.
Consider who is this innovation is for? Who needs to cooperate to make it available to the end user? Who will pay for it, either with hard cash or with their time and effort?

Another way to get a better understanding of the real problem you’re trying to solve is to write a short letter to the person you want to solve the problem for. A crucial part of innovating is to tell the story of the invention effectively, to make the people who need to care in that moment, care. It’s worth investing the time to get your story right and to seek out people you trust to give you honest feedback before you have to tell the story for real.

The importance of touch in the medical consultation. There is no app for that

When people are scared or in trouble what they want most is to be touched. Information alone is never enough to satisfy the deepest human needs that bubble up when our bodies appear to malfunction. This was recognised generations ago and the role of doctor was socially ordained. Doctors are licensed to examine the body intimately. Any doctor who abuses this trust is severely punished. The examination provides the healer with the information required to make a diagnosis, but more importantly it comforts the sufferer through human contact.

When I was a ‘wet behind the ears’ GP trainee, my clinical mentor offered me two pieces of advice in relation to the medical consultation. He told me to always stand up to greet the patient as they walk into the room and to look for an opportunity to lay hands on the patient, even if only to take their pulse.

Innovators may be tempted to think that everything that takes place in the consultation can be distilled down to the exchange of information and advice. However the consultation is designed to promote healing by allowing people to express concern and empathy through verbal and nonverbal behaviour. The former requires excellent communication skills, the latter is conducted as a series of rituals: ‘inspection, palpation, percussion and auscultation‘. And even as the body is examined the patient needs to feel that the examiner is concerned and respectful. If this is done well, healing can begin, sometimes against the odds.

This has important implications for innovation in health care. It’s not possible to interrupt or diminish the direct association between the doctor and the patient with gadgets or gizmos. If we do we may lose more than we gain.

Rethinking The Benefits Of Expensive Medical Research

In the developed world the really scary diagnoses are very uncommon. More often than not a patient’s symptoms can be safely interpreted as benign. This has engendered a false sense of security because there is evidence that doctors fail to recognise presentations of some nasty diseases.

Innovators in medicine have been focused on this problem for some time. For example a research team reported in 2009 that skin cancer was much easier to diagnose with the aid of a handheld device that draws attention to cancerous changes. The problem however is that doctors need to attend a course on dermatology and take an exam before it is safe to let them lose on people with the instrument. The published report was upbeat despite the fact that one in three doctors didn’t complete the required training. The outcome of this research (and many other research programs funded using millions in taxpayer dollars), was an academic paper that will never impact on the early diagnosis of the disease.

Less than five years later some of the same team were back to test a simpler device but with a similar requirement for education of doctors before successful deployment. The negative results were hardly surprising. The team concluded that cancer was more likely to be diagnosed early if doctors followed guidelines.

History has taught us that just because an intervention may be of benefit to patients, that doesn’t mean it is likely to be embraced by overburdened care providers trying to earn a living. The most successful innovators understand the need to tailor interventions to meet the needs of both the health professional and her patient. They realise that tools that are inconvenient or cumbersome are doomed to novelty status.

Committees that determine which ideas are worthy often deny the lessons of agile, intuitive, creative and effective innovations. These are more likely to be reliable, developed relatively cheaply and don’t need an instruction manual.
How hard is it to adopt your innovative ideas in practice?

Innovating in cancer diagnosis and treatment

The experience of someone with cancer is a litmus test of a country’s healthcare system. Let me explain:

Cancer Symptoms

The symptoms of many cancers are very like those of many more benign conditions. Take colorectal (bowel) cancer. People who develop this disease present with symptoms that many of us have had at some point in our lives—diarrhoea, rectal bleeding, abdominal pain and fatigue. You would imagine that the symptoms of bowel cancer are far worse than anything following a suspect meal. In some cases, yes, they are. In many cases those who develop widespread, incurable disease have quite minor and short lived symptoms.

Despite the wide availability of screening tests, the majority of bowel cancer diagnoses in the developed world happens after presenting to a doctor with symptoms. Those who are ‘lucky’ present with lots of symptoms, but have a curable cancer. Many patients present with late and incurable disease, sometimes with relatively minor symptoms. Studies of people who turn up with symptoms, suggests that there are patterns that describe cases more likely to have the condition. However these patterns are not reliable and in many cases the chance of being diagnosed with cancer, despite the ‘data’ is, thankfully, relatively small. That means that of all those who present with symptoms for the first time, it is the communication skills of the doctor they consult that determines if that person is identified as someone who would benefit from a colonoscopy. But also , crucially, whether the person who is at no risk at all is subjected to a colonoscopy.

The reality seems to be that more people have a colonoscopy, than benefit from the experience. The greatest gripe in many health care systems is that people are left to languish on waiting lists. The finger is pointed either at primary care for selecting too many patients for referral, or at hospitals for not providing enough clinics. In my view the truth is that neither is to blame. Humans vary in their ability to seek help, they vary in their ability to apportion limited resources and in the end the system depends on people. Our human frailty is the weak link.

Cancer Treatment

Once ‘in the system’ the patient is subjected to all that can be offered by the King’s horses and men. Large sections of their anatomy may be removed. Chemicals and radiation may be administered, and weeks if not months of their lives may be spent in an alien, clinical environment. Here they have to adjust to life without the familiar and predictable. Many make a full recovery, which is testimony to the resilience of human beings. Some don’t make it and the rest never fully recover, if not from the cancer, then from the effects of the efforts to save their lives. While being treated they are segregated from their families, their support structures, including their family doctor, who will be consulted in the future, about the diarrhoea, the fatigue, the urinary and sexual dysfunction and the fear of recurrence that may be a feature of life after bowel cancer.

Cancer Support

What happens after this ordeal is that people either recover fully and rarely need to think about it again, or continue to suffer debilitating side effects related to the assault on their physical, psychological and social self. In these circumstances the health care system is either supportive and offers all manner of ‘interventions’, or barely supports people who have been ‘cured’ of cancer and now need to get their lives back on track. When the health sectors are divided along funding lines, as is the case in Australia, the scope for it to be someone else’s job are greatly increased. In these circumstances we can detect so-called ‘unmet need’.

Innovation In Cancer Care

Academic careers are being made of documenting all of this. It sounds like chronicling what common sense already tells us. It’s about lack of knowledge, unhelpful attitudes and questionable beliefs. But as a proponent of ‘lean medicine’, I wonder if those who refer people for life saving treatment and then pick up the pieces have something to offer? Can we generate solutions, rather than apply for yet more tax payer’s money to explore what our patients and colleagues are already telling us? The challenge is that we already have a growing demand in primary care, based on the rising incidence of chronic and complex conditions, consequent to an aging population and poor life style choices. How can the care of these patients be improved without relying on people recognising it as simply ‘the right thing to do’? How can we generate a solution that makes life better for everyone. Failure to do so has brought us to the current impasse, and the aforementioned ‘unmet need’. A lean medical solution will allow people to access, and assimilate more information about their symptoms, their treatment and life after treatment. Perhaps it will empower practitioners to be more proactive, without having to increase an already overburdened health work force?

What are your ideas to improve things for the one in four people who will develop cancer in the course of their lives?

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?

Symptom or disease? The four circle rule.

Four Circles for innovators in Lean Medicine

Four Circles for innovators in Lean Medicine

Most people with symptoms don’t seek medical advice. Those who choose to make an appointment with a doctor are more likely to have a disease and those who are referred to a hospital specialist are even more likely to have pathology. Lean medicine takes account of Bayes’ theorem that demonstrates this simple truth mathematically.

I like to think of it as ‘the four circles rule’.
This schematic tells us that many people with pathology do not seek medical advice and some don’t even have symptoms. It also tells us that doctors have to find those with pathology from among the many who do seek their advice. Often patients present with a host of problems, so that the four circles become 8, 12, 16 or even 20 different circles, one set for each condition.

My team have applied this principle to study people with bowel symptoms. It is a fact that most people with bowel symptoms do not have pathology, or at least not cancer. Epidemiologists have identified groups of symptoms which when they occur together are most likely to signify pathology. This isn’t always reliable and there are lots of false positives, leading to anxiety among the worried well. On the other hand it is also true that people with pathology may or may not seek medical advice. The latter is especially true of men who find discussing their bowels embarrassing. Sometimes so much so that they don’t mention the diarrhoea or rectal bleeding to anyone, least of all their doctor. The consequences are that in some cases they delay seeking help for potentially life limiting disease until it is too late for curative treatment.

We also know that colorectal cancer is diagnosed in most cases only after the patient has developed symptoms and sought medical advice. Only a minority of cases are diagnosed from among those with no symptoms who have been screened for the disease. Whatever the case the sooner a diagnosis is made the better the chances of successful treatment. Because the symptoms can be so embarrassing and to some extent because some men procrastinate with seeking advice colorectal cancer has a worse prognosis in men.

It’s in situations like these that innovations which are low cost, personalised and offer creative solutions to healthcare problems come into their own. The focus could be to provide opportunities for as many people as possible to get convenient, reliable, personalised information in privacy without necessarily going to a doctor. What’s more such an innovation needs to make life easier for the practitioner and the patient.

The context is often private and confidential

7257592240_6759efd5a5_zThe consultation between a doctor and patient is private. Innovators hoping to improve outcomes in that context can’t observe the exchange directly because some presentations are very uncommon and because neither the doctor nor the patient welcomes the intrusion. There are many outcomes of the encounter between patient and doctor that we still don’t fully understand. Why are some patients’ cancer symptoms not recognised as early warnings? Why do carers of patients with a life-limiting illness fail to have their own medical problems addressed? Why do people living with some chronic conditions continue to have problems with intimacy?

People deploy verbal and non-verbal cues to communicate. They choose when and how to disclose their ideas, concerns and expectations. However in an average consultation in my country, the patient has fifteen minutes to ‘spit it out’. Similarly, clinicians vary in their ability to pick up cues or to probe with the right question, assuming they get the right answer. Hence errors of omission and or commission.

Lean medicine is about being intuitive, creative and agile. Lean innovators, clinicians, are already on site. Therefore, they can reproduce the context in a way that can be observed and where they can be tested with other clinicians. Video technology and a fusion of skills across disciplines allow the depiction of those encounters in such a way as to present the critical decision point for close examination. Do you prescribe, refer or investigate in these circumstances? What do you say to the patient?

How do you explore hard to reach elements in your practice or business? How can you hope to innovate for encounters that are strictly private and confidential but where mistakes or misunderstanding can be very bad for business. Who has the insight to show you? How can you generate valid hypotheses? How do you test ideas without a real risk of casualties?

Picture by Urbanbohemian